Catad_tema Surgical diseases - articles

Standard of medical care for patients with strangulated hernia

On November 26, 2007, the Ministry of Health approved protocols for the diagnosis and treatment of strangulated hernia.

Strangulated hernia(ICD - 10 K40.3 - K 45.8) - sudden or gradual compression of the contents of the hernia at its gate.

Strangulation is the most common and dangerous complication of hernia disease. Mortality of patients increases with age, varying between 3.8 and 11%. Necrosis of strangulated organs is observed in at least 10% of cases.

The forms of infringement are different. Among them are:
1) elastic infringement;
2) fecal impaction;
3) parietal infringement;
4) retrograde infringement;
5) Litre hernia (strangulation of Meckel's diverticulum).

According to the frequency of occurrence, the following are observed:
1) strangulated inguinal hernia
2) strangulated femoral hernia;
3) strangulated umbilical hernia;
4) strangulated postoperative ventral hernias;
5) strangulated hernia of the white line of the abdomen;
6) strangulated hernias of rare localizations.

A strangulated hernia may be accompanied by acute intestinal obstruction, which occurs through the mechanism of strangulation intestinal obstruction, the severity of which depends on the level of strangulation.
For all types and forms of strangulated hernia, the severity of the disorder is directly dependent on the time factor, which determines the urgent nature of diagnostic and treatment measures.

Protocols for diagnosing strangulated hernias in the emergency department (EMD)

Patients admitted to the emergency department with complaints of abdominal pain and symptoms of acute intestinal obstruction should be specifically examined for the presence of hernial protrusions in typical places.

Based on complaints, clinical history and objective examination data, patients with strangulated hernias should be divided into 4 groups:
Group 1 - uncomplicated strangulated hernia;
Group 2 - complicated strangulated hernia

For complicated strangulated hernia, 2 subgroups are distinguished:
a) strangulated hernia, complicated by acute intestinal obstruction;
b) strangulated hernia, complicated by phlegmon of the hernial sac.
Group 3 - reduced strangulated hernia;

Uncomplicated strangulated hernia;

Criteria for diagnosing an uncomplicated strangulated hernia in the EDMS:

A strangulated uncomplicated hernia is recognized by:
- sudden onset of pain in the area of ​​a previously reduced hernia, the nature and intensity of which depends on the type of infringement, the affected organ and the age of the patient;
- impossibility of reducing a previously freely reducible hernia;
- increase in the volume of hernial protrusion;
- tension and pain in the area of ​​the hernial protrusion;
- absence of transmission of the “cough impulse”;

There are no symptoms and signs of acute intestinal obstruction with an uncomplicated strangulated hernia.

Laboratory research:
- clinical blood test,
- blood group and Rh factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical urine analysis.

- ECG

Therapist consultations

Protocols for preoperative preparation for uncomplicated incarcerated hernia in the emergency department

Protocols of surgical tactics for uncomplicated strangulated hernia.

1. The only method of treatment for patients with a strangulated uncomplicated hernia is emergency surgery, which should be started no later than 2 hours from the moment the patient is admitted to the emergency department. There are no contraindications to surgery for a strangulated hernia.
2. The main objectives of the operation in the treatment of uncomplicated strangulated hernias are:
- elimination of infringement;
- examination of injured organs and appropriate interventions on them;
- plastic surgery of hernial orifices.
3. An incision of sufficient size is made in accordance with the location of the hernia. The hernial sac is opened and the organ strangulated in it is fixed. Dissection of the strangulating ring before opening the hernial sac is unacceptable.
4. If a strangulated organ spontaneously reduces into the abdominal cavity, it should be removed for inspection and assessment of its blood supply. If it cannot be found and removed, wound expansion (herniolaparotomy) or diagnostic laparoscopy is indicated.
5. After dissection of the strangulated ring, the condition of the strangulated organ is assessed. A viable intestine quickly takes on a normal appearance, its color becomes pink, the serous membrane is shiny, peristalsis is clear, the mesenteric vessels pulsate. Before repositioning the intestine into the abdominal cavity, it is necessary to inject 100 ml of a 0.25% novocaine solution into its mesentery.
6. If there are doubts about the viability of the intestine, 100 - 120 ml of a 0.25% novocaine solution should be injected into its mesentery and the doubtful area should be warmed with warm tampons soaked in 0.9% NaCl. If doubt about the viability of the bowel remains, the bowel should be resected within healthy tissue.
7. Signs of intestinal non-viability and undisputed indications for its resection are:
- dark color of the intestine;
- dull serous membrane;
- flabby wall;
- lack of intestinal peristalsis;
- absence of pulsation of the vessels of its mesentery;
8. In addition to the strangulated section of the intestine, the entire macroscopically changed part of the adducting and efferent colon plus 30 - 40 cm of the unchanged section of the adductor colon and 15 - 20 cm of the unchanged segment of the efferent colon are subject to resection. The exception is resection near the ileocecal angle, where it is possible to limit these requirements with favorable visual characteristics of the intestine in the area of ​​the intended intersection. In this case, control indicators of bleeding from the vessels of the wall when crossing it and the condition of the mucous membrane are necessarily used. It is also possible to use transillumination or other objective methods for assessing blood supply. During intestinal resection, when the level of anastomosis is at the most distal part of the ileum - less than 15 - 20 cm from the cecum, one should resort to ileoascendo - or ileotransverse anastomosis.
9. If there are doubts about the viability of the intestine, especially over a large extent, it is permissible to postpone the decision on resection, using programmed laparoscopy after 12 hours.
10. In cases of parietal strangulation, intestinal resection should be performed. Immersion of a changed area into the intestinal lumen is dangerous and should not be done, since this may cause divergence of the immersing sutures, and immersion of a large area within the unchanged parts of the intestine can create a mechanical obstacle that impairs intestinal patency.
11. Restoring the continuity of the gastrointestinal tract after resection is carried out:
- with a large difference in the diameters of the lumens of the sections of the intestine to be sewn together with a side-to-side anastomosis;
- if the diameters of the lumens of the stitched sections of the intestine coincide, it is possible to use an end-to-end anastomosis.
12. If the omentum is strangulated, indications for its resection are given if it is swollen, has fibrinous deposits or hemorrhages.
13. The surgical intervention ends with plastic surgery of the hernial orifice, depending on the location of the hernia.

Protocols for postoperative management of patients with uncomplicated strangulated hernia

2. All patients are prescribed intramuscular administration of painkillers (analgin, ketarol) 3 times a day for 3 days after surgery; broad-spectrum antibiotics (cefazolin 1 g x 2 times a day) for 5 days after surgery.

Complicated strangulated hernia

Strangulated hernia complicated by acute intestinal obstruction

Criteria for diagnosing a strangulated hernia complicated by intestinal obstruction in the emergency department:

Local symptoms of strangulation are accompanied by symptoms of acute intestinal obstruction:
- cramping pain in the area of ​​the hernial protrusion
- thirst, dry mouth,
- tachycardia > 90 beats. in 1 min.
- recurrent vomiting;
- delay in the passage of gases;
- during the examination, abdominal bloating and increased peristalsis are determined; M.B. "splash noise";
- on a survey radiograph, Kloiber's cups and small intestinal arches with transverse striations are determined, the presence of an “isolated loop” is possible;
- Ultrasound examination reveals dilated intestinal loops and “pendulum-like” peristalsis;

Examination protocols in OEMP

Laboratory research:
- clinical blood test,
- blood group and Rh factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical urine analysis.

Instrumental studies:
- ECG
- Plain radiography of the chest organs
- Plain radiography of the abdominal cavity.
- Ultrasound of the abdominal cavity.

Therapist consultations

Protocols for preoperative preparation of strangulated hernia complicated by intestinal obstruction in the emergency department

1. Before the operation, it is mandatory to insert a gastric tube and evacuate the gastric contents.
2. The bladder is emptied and the surgical area and the entire anterior abdominal wall are hygienically prepared.
3. The presence of pronounced clinical signs of general dehydration and endotoxemia serves as an indication for intensive preoperative preparation with placement of a catheter in the main vein and infusion therapy (intravenous 1.5 liters of crystalloid solutions, reamberin 400 ml, 10 ml diluted with 400 ml of 5% glucose solution In this case, antibiotics are administered intravenously 30 minutes before surgery.

Protocols of surgical tactics for strangulated hernia complicated by intestinal obstruction.

1. Surgery for a complicated strangulated hernia is always performed under anesthesia by a three-medical team with the participation of the most experienced surgeon of the duty team or the responsible surgeon on duty no later than 2 hours from the moment the patient is admitted to the hospital.
2. The main objectives of the operation in the treatment of a strangulated hernia complicated by intestinal obstruction are:
- elimination of infringement;
- determination of intestinal viability and determination of indications for its resection;
- establishing the boundaries of resection of the altered intestine and its implementation;
- determination of indications and method of intestinal drainage;
- sanitation and drainage of the abdominal cavity
- plastic surgery of hernial orifices.

3. The initial stages of the operation to eliminate a strangulated hernia complicated by intestinal obstruction correspond to the provisions set out in paragraphs. 5 - 12 surgical tactics for uncomplicated strangulated hernia.
4. The indication for drainage of the small intestine is overflow of the afferent intestinal loops with contents.
5. The preferred method of drainage of the small intestine is nasogastrointestinal intubation from a separate midline laparotomy access.
6. The surgical intervention ends with drainage of the abdominal cavity and plastic surgery of the hernial orifice, depending on the location of the hernia.

Protocols for postoperative management of patients with strangulated hernia complicated by intestinal obstruction

1. Enteral nutrition begins with the appearance of intestinal peristalsis through the introduction of glucose-electrolyte mixtures into the intestinal tube.
2. Removal of the nasogastrointestinal drainage probe is carried out after the restoration of stable peristalsis and independent stool for 3-4 days. The drainage tube installed in the small intestine through a gastrostomy or retrograde according to Welch-Zhitnyuk is removed somewhat later - on days 4-6.
3. In order to combat ischemic and reperfusion injuries of the small intestine, infusion therapy is carried out (intravenous 2-2.5 liters of crystalloid solutions, reamberin 400 ml, 10.0 ml diluted per 400 ml of 0.9% sodium chloride solution, trental 5, 0 - 3 times a day, contrical - 50,000 units/day, ascorbic acid 5% 10 ml/day).
4. Antibacterial therapy in the postoperative period should include either aminoglycosides II-III, cephalosporins of the third generation and metronidozole, or fluoroquinolones of the second generation and metronidozole.
5. To prevent the formation of acute gastrointestinal ulcers, therapy should include antisecretory drugs.
6.Complex therapy should include heparin or low molecular weight heparins to prevent thromboembolic complications and microcirculation disorders.
Laboratory tests are performed as indicated and before discharge. In case of uncomplicated postoperative period, discharge is made on the 10-12th day.

Strangulated hernia, complicated by phlegmon of the hernial sac

Criteria for diagnosing a strangulated hernia complicated by phlegmon of the hernial sac in the EDMP:
- presence of symptoms of severe endotoxicosis;
- presence of fever;
- hernial protrusion is swollen, hot to the touch;
- hyperemia of the skin and swelling of the subcutaneous tissue, spreading far beyond the hernial protrusion;
- there may be crepitation in the tissues surrounding the hernial protrusion.

Examination protocols in OEMP

Laboratory research:
- clinical blood test,
- blood group and Rh factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical urine analysis.

Instrumental studies:
- ECG
- Plain radiography of the chest organs
- Plain radiography of the abdominal cavity.

Therapist consultations

Protocols for preoperative preparation of strangulated hernia complicated by phlegmon of the hernial sac in the ED

1. Before the operation, it is mandatory to insert a gastric tube and evacuate the gastric contents.
2. The bladder is emptied and the surgical area and the entire anterior abdominal wall are hygienically prepared.
3. Intensive preoperative preparation is indicated with insertion of a catheter into the main vein and administration of infusion therapy (1.5 liters of crystalloid solutions intravenously, reamberin 400 ml,
4. It is mandatory to administer broad-spectrum antibiotics (III generation cephalosporins and metronidazole) 30 minutes before surgery intravenously.

Protocols of surgical tactics for strangulated hernia complicated by phlegmon of the hernial sac.

1. Surgery for a complicated strangulated hernia is always performed under anesthesia by a three-medical team with the participation of the most experienced surgeon of the duty team or the responsible surgeon on duty no later than 2 hours from the moment the patient is admitted to the hospital.
2.Surgery begins with a median laparotomy. If the loops of the small intestine are pinched, resection is performed with anastomosis. The question of how to complete the colon resection is decided individually. The ends of the intestine to be removed are sutured tightly. Then a purse-string suture is placed on the peritoneum around the inner ring of the hernial orifice. The intra-abdominal stage of the operation is temporarily stopped.
3. Herniotomy is performed. The strangulated necrotic part of the intestine is removed through a herniotomy incision with simultaneous tightening of the purse-string suture inside the abdominal cavity. In this case, special attention is paid to preventing the entry of inflammatory purulent-putrefactive exudate of the hernial sac into the abdominal cavity.
4. Primary repair of the hernial orifice is not performed. In the herniotomy wound, necrectomy is performed, followed by loose packing and drainage.
5. According to indications, drainage of the small intestine is performed.
6. The operation ends with drainage of the abdominal cavity.

Protocols for postoperative management of patients with strangulated hernia complicated by phlegmon of the hernial sac.

1. Local treatment of a herniotomy wound is carried out in accordance with the principles of treatment of purulent wounds. Dressings are performed daily.
2. Detoxification therapy includes intravenous administration of 2-2.5 liters of crystalloid solutions, reamberin 400 ml, 10.0 ml diluted per 400 ml of 0.9% sodium chloride solution, trental 5.0 - 3 times a day, contrical - 50,000 units/day, ascorbic acid 5% 10 ml/day.
3. Antibacterial therapy in the postoperative period should include either aminoglycosides II-III, cephalosporins of the third generation and metronidozole, or fluoroquinolones of the second generation and metronidozole.
4. To prevent the formation of acute gastrointestinal ulcers, therapy should include antisecretory drugs.
5.Complex therapy should include heparin or low molecular weight heparins to prevent thromboembolic complications and microcirculation disorders.
Laboratory tests are performed as indicated and before discharge.

Reduced strangulated hernia.

Criteria for diagnosing a reduced strangulated hernia of the EMP:

The diagnosis of “strangulated hernia, condition after strangulation” can be made when there are clear indications from the patient himself of the fact of strangulation of a previously reduced hernia, the period of time of its non-reduction and the fact of its independent reduction.

A reduced strangulated hernia should also be considered a hernia, the fact of self-reduction of which occurred (and is recorded in medical documents) in the presence of medical personnel (at the prehospital stage - in the presence of emergency medical personnel, after hospitalization - in the presence of the duty surgeon of the EDMC).

Examination protocols in OEMP

Laboratory research:
- clinical blood test,
- blood group and Rh factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical urine analysis.

Instrumental studies:
- ECG
- Plain radiography of the chest organs
- Plain radiography of the abdominal cavity.

Therapist consultations

Protocols for preoperative preparation of reduced strangulated hernia in the EDMP

1. Before the operation, it is mandatory to insert a gastric tube and evacuate the gastric contents.
2. The bladder is emptied and the surgical area and the entire anterior abdominal wall are hygienically prepared.

Protocols of surgical tactics for reduced strangulated hernia.

1. When a strangulated hernia is repaired and the strangulation lasts less than 2 hours, hospitalization in the surgical department is indicated, followed by dynamic observation for 24 hours.
2. If during dynamic observation there are symptoms of deterioration in the general condition of the observed person, as well as peritoneal symptoms, diagnostic laparoscopy is indicated.
3. When self-reducing a strangulated hernia before hospitalization, if the fact of strangulation is beyond doubt, and the duration of strangulation is 2 hours or more, diagnostic laparoscopy is indicated.

Protocols for the management of patients with reduced strangulated hernia.

Postoperative management of patients after diagnostic laparoscopy is determined by diagnostic findings and the extent of surgical intervention for them.

Strangulated postoperative ventral hernia

Criteria for diagnosing a strangulated postoperative ventral hernia of the EMP:
- the clinical picture depends on its size, type of infringement and severity of intestinal obstruction. There are fecal and elastic strangulation.
- with fecal impaction, a gradual onset of the disease is observed. Constantly existing pain in the area of ​​the hernial protrusion increases, becomes cramping in nature, and subsequently symptoms of acute intestinal obstruction occur - vomiting, gas retention, lack of stool, and bloating. The hernial protrusion does not decrease in the supine position and acquires clear contours.
- elastic strangulation is typical for hernias with small hernial orifices. There is a sudden onset of pain due to the introduction of a large segment of intestine into the hernial sac through a small defect in the anterior abdominal wall. Subsequently, the pain syndrome intensifies and symptoms of intestinal obstruction appear.
- the main symptoms of a strangulated postoperative ventral hernia are:
- pain in the area of ​​hernial protrusion;
- irreducible hernia;
- sharp pain upon palpation of the hernial protrusion;
- with a long period of strangulation, clinical and radiological signs of intestinal obstruction are possible.

Examination protocols in OEMP

Laboratory research:
- clinical blood test,
- blood group and Rh factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical urine analysis.

Instrumental studies:
- ECG
- Plain radiography of the chest organs
- Plain radiography of the abdominal cavity.

Therapist consultations

Protocols for preoperative preparation of strangulated postoperative ventral hernia in the ED.

1. Before the operation, it is mandatory to insert a gastric tube and evacuate the gastric contents.
2. The bladder is emptied and the surgical area and the entire anterior abdominal wall are hygienically prepared.
3. In the presence of intestinal obstruction, intensive preoperative preparation is indicated with the placement of a catheter in the main vein and infusion therapy (intravenous 1.5 liters of crystalloid solutions, reamberin 400 ml, 10 ml diluted with 400 ml of 5% glucose solution) for 1 hour or on the operating table, or in the surgical department.

Protocols of surgical tactics for strangulated postoperative ventral hernia.

1. Treatment of a strangulated postoperative ventral hernia consists of performing an emergency laparotomy within 2 hours from the moment of admission to the hospital.
2. Objectives of surgical treatment for strangulated postoperative ventral hernia:
- thorough revision of the hernial sac, taking into account its multi-chamber nature and elimination of the adhesive process;
- assessment of the viability of the organ strangulated in the hernia;
- if there are signs of non-viability of the strangulated organ - its resection.
3. In case of strangulation of large multi-chamber postoperative ventral hernias of the abdominal wall, the operation is completed by dissecting all fibrous septa and suturing only the skin with subcutaneous tissue.
4. In case of an extensive hernia defect more than 10 cm in diameter, in order to prevent abdominal compartment syndrome, it is possible to close the hernial orifice with a mesh explant.

Protocols for postoperative management of patients with strangulated postoperative ventral hernia.

1. Treatment of patients with a strangulated postoperative ventral hernia until hemodynamics are stabilized and spontaneous breathing is restored is carried out in the medical department.
2. Therapeutic measures in the postoperative period should be aimed at:
- suppression of infection by prescribing antibacterial agents;
- fight against intoxication and metabolic disorders;
- treatment of complications from the respiratory and cardiovascular systems;
- restoration of gastrointestinal function.

Strangulated hernia complicated by peritonitis

Criteria for diagnosing a strangulated hernia complicated by peritonitis in the EMF:
- general condition is serious;
- symptoms of severe endotoxicosis: confused consciousness, dry mouth, tachycardia > 100 beats. in 1 min., hypotension 100 - 80/ 60 - 40 mm. Hg;
- periodic vomiting of stagnant or intestinal contents;
- during the examination, abdominal bloating, lack of peristalsis, and a positive Shetkin-Blumberg sign are determined;
- multiple fluid levels are determined on a plain radiograph;
- Ultrasound examination reveals dilated intestinal loops;

Examination protocols in OEMP

Laboratory research:
- clinical blood test,
- blood group and Rh factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical urine analysis.

Instrumental studies:
- ECG
- Plain radiography of the chest organs
- Plain radiography of the abdominal cavity.

Therapist consultations
Examination by a resuscitator

Protocols for preoperative preparation of strangulated hernia complicated by peritonitis in the emergency department

1. Preoperative preparation and diagnosis are carried out in a surgical environment.
2. A gastric tube is inserted and the gastric contents are evacuated.
Intensive preoperative preparation is indicated with placement of a catheter in the main vein and infusion therapy (intravenous 1.5 liters of crystalloid solutions, reamberin 400 ml, 10 ml diluted with 400 ml of 5% glucose solution) for 1 hour either on the operating table or in OHR.
3. It is mandatory to administer broad-spectrum antibiotics (III generation cephalosporins and metronidazole) 30 minutes before surgery intravenously.
4. The bladder is emptied and the surgical area and the entire anterior abdominal wall are hygienically prepared.

Protocols of surgical tactics for strangulated hernia complicated by peritonitis.
1. Surgery for a complicated strangulated hernia is always performed under anesthesia by a three-medical team with the participation of the most experienced surgeon of the duty team or the responsible surgeon on duty.
2.Surgery begins with a median laparotomy.

Attempts to reduce a strangulated hernia are contraindicated.

The diagnosis of a reduced strangulated hernia can be made when there are clear indications from the patient himself about the fact of strangulation of a previously reduced hernia, the period of time of its non-reduction and the fact of its independent reduction. A reduced strangulated hernia should also be considered a hernia, the fact of self-reduction of which occurred (and is recorded in medical documents) in the presence of medical personnel (at the prehospital stage - in the presence of emergency medical personnel, after hospitalization - in the presence of the duty surgeon of the EDMC).

Group 4 - strangulated postoperative ventral hernia

Strangulation of postoperative ventral hernias is observed in 6 - 13% of cases. The clinical picture depends on its size, type of strangulation and severity of intestinal obstruction. There are fecal and elastic strangulation.
With fecal strangulation, a gradual onset of the disease is observed. Constantly existing pain in the area of ​​the hernial protrusion increases, becomes cramping in nature, and subsequently symptoms of acute intestinal obstruction occur - vomiting, gas retention, lack of stool, and bloating. The hernial protrusion does not decrease in the supine position and acquires clear contours.
Elastic strangulation is typical for hernias with small hernial orifices. There is a sudden onset of pain due to the introduction of a large segment of intestine into the hernial sac through a small defect in the anterior abdominal wall. Subsequently, the pain syndrome intensifies and symptoms of intestinal obstruction appear.

Examination protocols in OEMP

Laboratory research:
- clinical blood test,
- blood group and Rh factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical urine analysis.

Instrumental studies:
- ECG
- Plain radiography of the chest organs
- Plain radiography of the abdominal cavity.
- Ultrasound of the abdominal cavity and hernial protrusion - according to indications

Therapist consultations
Consultation with an anesthesiologist (if indicated)

Once a diagnosis of strangulated hernia has been established, the patient is immediately sent to the operating room.

Protocols for preoperative preparation in the EDMC

1. Before the operation, it is mandatory to insert a gastric tube and evacuate the gastric contents.
2. The bladder is emptied and the surgical area and the entire anterior abdominal wall are hygienically prepared.
3. If there is a complicated strangulated hernia and a serious condition, the patient is sent to the surgical intensive care unit, where intensive therapy is carried out for 1-2 hours, including active aspiration of gastric contents, infusion therapy aimed at stabilizing hemodynamics and restoring the input-electrolyte balance, as well as or antibiotic therapy. After preoperative preparation, the patient is sent to the operating room.

II. Protocols for anesthetic performance of surgery

1. In case of strangulation of inguinal and femoral hernias with short periods of strangulation, general satisfactory condition, absence of symptoms of acute intestinal obstruction, surgical intervention can be started under local infiltration anesthesia to visually assess the viability of the organ strangulated in the hernia.
2. The method of choice is endotracheal anesthesia.

III. Protocols for differentiated surgical tactics

13. For strangulated hernias complicated by small intestinal obstruction, drainage of the small intestine is performed using a nasogastrointestinal tube
14. For phlegmon of the hernial sac, the operation is performed in 2 stages. The first stage is laparotomy. In the abdominal cavity, resection of the strangulated organ is performed, delimiting the hernial sac and its contents from the abdominal cavity with a purse-string suture. The second stage is herniotomy with removal of the strangulated organ outside the abdominal cavity. Plastic surgery of the hernial orifice for phlegmon of the hernial sac is not performed.
15. The surgical intervention ends with plastic closure of the hernial orifice. The nature of the repair is determined by the location and type of hernia. Hernial orifice repair is not performed for giant multilocular postoperative ventral hernias.

VI. Protocols for postoperative management of patients with uncomplicated course

1. A general blood test is prescribed one day after surgery and before discharge from the hospital.
2. All patients are prescribed intramuscular administration of painkillers (analgin, ketarol) on days 1–3 after surgery; broad-spectrum antibiotics (cefazolin 1 g x 2 times a day) for 5 days after surgery.
3. Sutures are removed on days 8-10, the day before patients are discharged for treatment at the clinic.
4. Treatment of developing complications is carried out in accordance with their nature

A strangulated hernia is a dangerous complication of a typical hernia and, due to its frequency of occurrence, is considered a separate nosological disease. The basis of the disease is pinching of the hernial sac in the hernial orifice with compression of the tissues and organs that are located in it. The greatest danger is posed by compression of the intestinal loop, since this causes the phenomenon of strangulation intestinal obstruction and necrosis of part of the intestine.

Kinds

Depending on the location, strangulated hernias are:

• postoperative (ventral);
• atypical areas (Spihelian line, internal);
• post-traumatic, associated with damage to the muscular aponeurosis (median, lateral).

According to clinical variants of the course:

Type of infringement	Characteristic
Elastic	Occurs due to a significant and sudden increase in pressure in the abdominal cavity. At the same time, a larger number of different structures emerge into the already formed hernial sac (pronounced expansion of the hernial orifice). When the hernia returns to its original state, strangulation occurs.
	Occurs when the outlet portion of the intestine is compressed. In the projection of the hernia, a crowded adductor colon is clearly visualized, which compresses the efferent section directly at the hernial orifice.
Parietal (Richter)		There is vascular pulsation and slight swelling may occur.	Thrombosis of mesenteric vessels.
Saving a function	Visible peristalsis.	Dumb gut.
Reaction after exposure to 15 minutes of saline wrap	The color takes on a normal pink tint.	The color does not change.

In the case of Littre's hernia, removal of Meckel's diverticulum is indicated, regardless of its viability, since it is a vestigial organ. To remove it, a ligature-purse string method is used (similar to an appendectomy).

In the preoperative period, stabilization of the patient (hemodynamics and saturation) is required. General anesthesia is used more often, since if there is a risk of intestinal damage, local anesthesia is unacceptable.

Main objectives of the operation:

• removal of the hernia and all its components;
• damage to internal organs;
• plastic closure of the defect to prevent relapses.

Some points in surgical tactics for different types of hernias are presented in the table.

	Peculiarities
	The skin and subcutaneous tissue are incised 2 cm above and parallel to the Poupartian ligament. Next, the aponeurosis of the external oblique muscle is dissected, capturing the internal inguinal ring. The hernial sac is separated from adjacent structures, excised and sutured. The anterior or posterior wall of the inguinal canal is fixed with a mesh and plastic surgery is performed. It is extremely rare for these hernias to cause strangulation of the intestine (according to indications, a section of the intestine or omentum is resected). This requires dissection of the posterior wall of the inguinal canal and intersection of muscle structures. This provides access to the intestines. If it is impossible to perform the operation through this incision, a standard midline laparotomy is performed. After removing a section of the affected intestine, an intestine-to-intestine anastomosis is performed or the stoma is brought out and the wound is sutured layer-by-layer.
Femoral	During the operation, the incision is made strictly in the medial direction. Sometimes femoral rather than inguinal approaches to the hernia are used. Only the Basini method is used as plastic surgery. Intestinal strangulation occurs extremely rarely; to eliminate it, the Ruggi-Parlavecchio resection method is used. From the inguinal approach, an incision is made that extends to the thigh, then the femoral canal is opened, the strangulated organs are immersed in the abdominal cavity, and the hernia is removed with plastic surgery of the inguinal canal.
Umbilical	The surgical approach includes two bordering incisions around the hernial protrusion. The tissue is cut layer by layer, including the aponeurotic ring around the navel on both sides. Next, the hernial sac is opened slightly from the side. The viability of the strangulated section of the intestine is assessed, if necessary, resection is performed and an end-to-end anastomosis is performed. The wound is sutured in layers with plastic surgery of the anterior abdominal wall. Sometimes a Grekov operation is performed (removal of the hernia en bloc with a strangulated ring). In this case, the intestine is intersected in the efferent and afferent sections (the strangulated part is cut off) and an anastomosis is performed.
White line	The hernial sac is opened, the viability of the strangulated tissues is checked and immersed in the abdominal cavity, and the hernia is excised. Plastic surgery is rarely done; simple suturing of the anterior abdominal wall is sufficient.
Postoperative	The bordering incision is made in the area of ​​the hernial protrusion. Next, if necessary, the strangulated ring is cut and the viable organs are immersed in the abdominal cavity. Sometimes the entire hernial sac is not removed, but the entrance gate is sutured in order to prevent relapses. Skin plastic surgery can be done using different methods depending on the indications.
Atypical	A classic surgical technique with the only difference being the increase in the number of accesses.
Domestic	Laparoscopy or midline laparotomy is indicated. The scope of further surgical intervention is determined by the specific situation. In most cases, the defects are simply sutured or covered with grafts.

In the postoperative period the following are indicated:

• antibiotic therapy - for prophylactic purposes;
• infusion therapy - taking into account daily fluid loss;
• substrate antioxidants and antihypoxants - in order to prevent ischemic processes in the intestine;
• thrombolytics – to prevent blood clots;
• proton pump blockers - to prevent ulcers.

The patient is on enteral nutrition for some time.

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A strangulated hernia is considered acute surgical condition, which should be treated immediately. The success of the operation largely depends on the type of pinching and the patient’s timely visit to the clinic.

Photo 1. If a hernia is strangulated, you should urgently call an ambulance. Source: Flickr (eceveryshop).

What is a strangulated hernia

Strangulated hernia - compression of the contents of the sac in the hernial orifice. In this case, metabolism in those structures and organs that make up the neoplasm is disrupted. When the muscles of the abdominal wall are tense, the hernial orifice expands, into which the internal organs fall out. The organs remain in a compressed position when the muscles contract back.

Any type of hernia can be strangulated, but the most serious for good health compression of internal organs in the abdominal cavity is considered.

Note! The main danger is that the patient may develop intestinal inflammation or obstruction.

Classification of infringement

There are several types of pathology depending on the causes and nature of the pathology.

Elastic pinch

It occurs due to physical overexertion, in which part of the internal organs comes out through the abdominal cavity. State causes ischemia and severe muscle spasms. Tissue death occurs within 1.5-2 hours.

Feces

Develops due to overflow of intestinal loops with feces. The distinctive feature of the problem is that The death of compressed cells occurs more slowly than with elastic entrapment.

Necrosis develops only 2 days after pinching. The main cause of fecal compression is a violation of the peristalsis of the digestive organs.

Parietal infringement

Loop of intestine partially compressed.

Mixed infringement

Considered an advanced stage of fecal strangulation when the compressed element increases in size and leads to stretching of the hernial orifice. They, in turn, put pressure on the efferent and efferent loops of the intestine.

Littre hernia

Characterized by rapid death of compressed tissues. It is more often observed when femoral or inguinal tumors are compressed. This type of strangulation occurs only in small hernias that have a narrow gate. It can be classified as a parietal strangulation, although the only difference is a faster course, leading to necrosis, since the hernial protrusion is much less well supplied with blood.

Retrograde entrapment

Several intestinal loops enter the hernial orifice, but only one of them is strangulated.

The cause of the pathology may be an overcrowding of the intestines with feces or excessive physical activity.

Photo 2. If there is a hernia, heavy physical activity is contraindicated. Source: Flickr (clement127)

Causes and mechanism of formation

The mechanism of development of the pathological condition is the same for all types of hernias. The protrusion consists of several main parts:

• gate - a hole formed in weakened ligaments and muscles;
• sac - the hernia cavity where soft tissues and internal organs enter;
• hernial contents are part of the organs that have penetrated through the portal of formation.

Note! Most often, the rectum, omentum or bladder enters the hernia cavity. After pinching, the internal organs cannot independently assume an anatomically correct position.

The main reason for education is increased intra-abdominal pressure, which is provoked by several factors:

• severe straining during bowel movements;
• prolonged cough;
• urinary pathologies;
• a sharp decrease in body weight;
• difficult labor;
• wearing too tight clothes and belts;
• gastroenterological problems.

Symptoms and signs

A strangulated hernia does not go unnoticed, since the condition is accompanied by a vivid clinical picture. Characteristic signs of the condition include:

1. Sharp pain, arising after tension in the press. The symptom develops against the background of a sharp decrease in blood pressure. Unpleasant sensations arise when a person tries to touch the elevation.
2. Pinched education is not set in place, despite successful previous attempts to reduce hernias.
3. Pulling and skin redness above the elevation.

Only a doctor can differentiate the type of pathology in question from diseases with similar symptoms. If the condition occurs in a child, then the patient becomes restless, loses appetite and sleep. Prolonged crying may cause a slight rise in temperature.

All of the listed signs should be the reason for immediate contact with a gastroenterologist, since subsequent recovery depends on the duration of oxygen starvation of the compressed tissues.

Diagnosis of pathology

Diagnosis of pathology includes visual inspection painful area. The doctor assesses the size and distribution of the protrusion, and also determines the degree of pain on palpation.

Note! When changing body position, the strangulated hernial sac does not change in size and does not disappear, which is typical for other types of elevations.

The doctor also checks the presence of a transmitting cough impulse, which is not typical for a pinched formation.

For an accurate diagnosis it is necessary radiography abdominal organs. Instrumental examination reveals intestinal obstruction. To differentiate a strangulated hernia from other types of formation, it is prescribed Ultrasound of internal organs.

Treatment of strangulated hernia

The problem is being dealt with only. Before the ambulance arrives, the patient takes a supine position, placing a small pillow under his head. Do not stand up, move, warm the painful area, or take painkillers. This leads to complications of the pathology and distortion of its clinical picture.

Goals and types of surgery

The purpose of the operation is relieve pressure from the hernial sac on the surrounding tissues and free the internal organs from the hernial orifice. These actions help preserve the health and life of the patient. With timely intervention, complete recovery is possible without complications.

After anesthesia, the surgeon removes the protrusion in two ways:

• standard,
• laparoscopic.

Standard surgery

Above the Rise cut the skin and then excise the pouch itself. After this, the compressed internal organ is fixed to its original position. If the tissues are not damaged, the doctor sets them back. Damaged and dead areas are removed along with the hernia. For hernial orifice repair, the doctor uses the person’s own tissue.

Laparoscopy

The intervention is less traumatic than standard surgery. Due to this, the rehabilitation period is reduced. Laparoscopy may not be used in all cases. Indications for surgery: small size of the protrusion, the patient does not have chronic diseases or symptoms of intoxication. At least 3 hours must pass from the moment of pinching of soft tissues to laparoscopy. Laparoscopy is not performed during pregnancy, in people with obesity and intestinal obstruction.

Minimally invasive surgery has advantages over standard intervention:

• the patient has no scars on the skin;
• the risk of complications is minimized;
• there are no injuries to surrounding tissues.

It is important! Laparoscopy is carried out in stages: punctures are made in the area of ​​elevation, through which miniature surgical instruments are then inserted. The process is carried out under the supervision of a video camera with which the instruments are equipped.

Preparation rules

The operation has virtually no contraindications, except for recent heart attacks and heart attacks. Preparation for the intervention is carried out quickly, since a strangulated hernia can be complicated by necrosis.

Possible complications

If fecal impaction is not removed in a timely manner, the patient develops symptoms of intoxication: the passage of gases stops; difficulties arise during defecation. Gradually, the vomit takes on the smell of feces.

Late help threatens death.

Photo 3. Speed ​​of care plays a key role in the treatment of a strangulated hernia.

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Umbilical hernia

A strangulated umbilical hernia occurs in surgical practice in 10% of cases in relation to all strangulated hernias. The clinical picture of strangulation that occurs against the background of a reducible hernia is so characteristic that it is difficult to confuse it with another pathology. However, it must be taken into account that umbilical hernias are most often irreducible and the adhesive process in this area can cause pain and adhesive intestinal obstruction, which is sometimes incorrectly regarded as a strangulated hernia. The only distinguishing feature is the presence or absence of transmission of a cough impulse. With small umbilical hernias, Richter's strangulation is possible, which presents certain difficulties for recognition, since parietal strangulation of the intestine is not accompanied by acute intestinal obstruction.

Surgical access with excision of the navel is used, since there are always pronounced skin changes around it. Two bordering incisions are made around the hernial protrusion. The hernial sac is opened not in the area of ​​the dome-shaped bottom, but somewhat to the side, in the body area. The aponeurotic ring is dissected in both directions in a horizontal or vertical direction. The latter (Sapezhko's operation) is preferable, since it allows you to switch to a full-fledged midline laparotomy to perform any required surgical procedure.

For phlegmon of the hernial sac, perform Grekov's operation(Fig. 49-5).

Rice. 49-5. Stage of Grekov's operation for a strangulated umbilical hernia, complicated by phlegmon of the hernial sac.

The essence of this method is as follows: the bordering skin incision is continued, slightly narrowing, through all layers of the abdominal wall, including the peritoneum, and thus the hernia is excised as a single block along with the pinching ring within the healthy tissue. Having entered the abdominal cavity, they cross the strangulated organ proximal to the strangulation and remove the entire hernia without releasing its contents. If the intestine has been strangulated, then an anastomosis is performed between its adducting and efferent sections, preferably “end to end.” If the omentum is strangulated, a ligature is applied to its proximal part, after which the hernia is removed en bloc.

Among the methods of plastic surgery of the aponeurosis of the anterior abdominal wall, either Sapezhko's method(Fig. 49-6), or Mayo way(See Figure 68-12).

Figure 49-6. Plastic surgery of the aponeurosis of the anterior abdominal wall according to Sapezhko for strangulated umbilical and postoperative hernias: a, b - stages of surgical intervention.

Rice. 68-12. Hernial orifice repair for umbilical hernia according to Mayo.

In both cases, a duplicative aponeurosis is created by applying U-shaped sutures.

Hernia of the white line of the abdomen

Classic strangulation of hernias of the white line of the abdomen is rare in surgical practice. Much more often, incarceration of preperitoneal fatty tissue, which protrudes through slit-like defects in the aponeurosis of the white line of the abdomen, is mistaken for a strangulated hernia. Nevertheless, there are also true strangulations with the presence of a loop of intestine in the hernial sac, most often of the Richter hernia type.

In this regard, during surgical intervention for a suspected strangulation of a hernia of the linea alba, it is necessary to carefully dissect the preperitoneal fatty tissue protruding through the defect of the linea alba. If a hernial sac is detected, it should be opened, the organ located in it should be examined and the hernial sac should be excised. If there is no hernial sac, a stitching ligature is applied to the base of the lipoma and cut off. For plastic closure of the hernial orifice, simple suturing of the aponeurosis defect with separate sutures is used. For multiple hernias, plastic surgery of the white line of the abdomen is used according to the Sapezhko method.

Postoperative ventral hernia

Strangulated postoperative ventral hernia is rare. Despite the large hernial orifice, strangulation can occur in one of the many chambers of the hernial sac through the fecal or elastic mechanism. Due to the existing extensive adhesions, kinks and deformations of the intestine in the area of ​​postoperative hernias, acute pain and the phenomenon of acute adhesive intestinal obstruction often occur, which are regarded as the result of a strangulated hernia. Such an error in diagnosis is not of fundamental importance, since in both cases it is necessary to perform an emergency operation.

Surgery for a strangulated postoperative hernia is performed under anesthesia, which allows for a sufficient inspection of the abdominal organs and suturing of the abdominal wall defect. The skin incision is made bordering, since it is sharply thinned over the hernial protrusion and is directly fused with the hernial sac and the underlying intestinal loops. After opening the hernial sac, the incarcerating ring is dissected, the contents are inspected and the viable organs are immersed in the abdominal cavity. Some surgeons do not isolate the hernial sac due to the significant trauma of this manipulation, but suture the hernial orifice inside it with separate sutures. For small defects, the edges of the aponeurosis or muscles are sutured “edge to edge.” For huge ventral hernias, which include most of the contents of the abdominal cavity, especially in elderly patients, the hernial orifice is not sutured, but only skin sutures are placed on the surgical wound. Complex methods of plastic surgery, especially with the use of alloplastic materials, are rarely used in such cases, since they greatly increase the risk of surgical intervention in these patients.

You can count on the success of alloplasty only by strictly observing the rules of asepsis. The synthetic “mesh,” if successful, is fixed in such a way that the edges of the aponeurosis are sutured over it (the intestine must be “fenced off” from the synthetic material by part of the hernial sac or the greater omentum). If this cannot be done, the “patch” is sewn to the outer surface of the aponeurosis. Be sure to drain the postoperative wound (with active aspiration for 2-3 days). All patients are prescribed broad-spectrum antibacterial drugs.

A.A. Matyushenko, V.V. Andriyashkin, A.I. Kiriyenko

Incarcerated hernia is the most common and most dangerous complication that can develop during the formation of a hernial sac of any location. Pathology develops regardless of a person’s age category. The main factor leading to pinching is an increase in intra-abdominal pressure or sudden lifting of heavy objects. However, a large number of other pathological and physiological sources may also contribute to this.

The clinical picture consists of quite specific symptoms, including: irreducibility of the hernial protrusion, pain of varying degrees of intensity and an increase in the size of the defect.

Pathology can be diagnosed using information obtained after studying the life history, data from an objective examination and instrumental examinations of the patient.

Treatment of a hiatal hernia or any pathology of any other location is carried out only through a hernia excision operation, during which resection of the contents of the sac can also be performed.

The International Classification of Diseases identifies several codes for such a disease. It follows from this that the ICD-10 code will be K40.3-K45.8.

Etiology

Regardless of where the pinched hernia is localized, the mechanism of development of the pathology will be similar for all options. In such situations, a process of compression of the tissues of the internal organs that enter the cavity of the hernial sac occurs.

All hernias include the following components:

• gate - represent a weakened opening in the ligaments or muscles;
• the bag is the cavity into which the internal organs directly fall;
• hernial contents are part of the organs penetrating into the pathological opening that forms between the ligaments. In the vast majority of situations, the constituent parts of the hernial sac are intestinal loops, the greater omentum, as well as part of the stomach or bladder, which cannot independently return to their normal anatomical location.

The main reason affecting hernia strangulation is an increase in intra-abdominal pressure, which, in turn, can be caused by:

• severe straining during bowel movements;
• coughing or sneezing;
• sudden lifting of weights;
• disturbance of the urination process;
• weakness of the abdominal muscles;
• traumatic injury to the abdomen;
• a sharp decrease in body weight;
• , and other gastroenterological diseases;
• strong crying or loud screaming - these are the fundamental sources of strangulation of the abdominal hernia in the navel area in children;
• difficult course of labor;
• the presence of any stage in the patient;
• wearing excessively tight belts or belts.

After intra-abdominal pressure returns to normal, a decrease in the size of the hernial orifice is observed, against the background of which the process of pinching of internal organs that extend beyond the hernia occurs. It is worth noting that the probability of the formation of such a process does not depend on the diameter of the gate of the pathological protrusion and its size.

Classification

Types of the disease depending on the location of the bag:

• strangulation of the umbilical hernia, which is most often diagnosed in children;
• strangulation of an inguinal hernia - this also includes the development of an inguinal-scrotal hernia in males;
• strangulation of diaphragmatic hernia;
• strangulation of the femoral hernia, which is very important to differentiate from the inguinal hernia sac. This is due to the fact that such diseases have an almost similar clinical picture;
• strangulation of a hernia of the white line of the abdomen;
• strangulation of a postoperative ventral hernia - diagnosed most rarely;
• strangulation of a Spigelian or semilunar hernia - in this case the focus is located on the line that connects the navel to the anterior upper part of the ilium;
• strangulation of lumbar hernia;
• strangulated sciatic hernia;
• strangulation of the obturator hernia.

Depending on the degree of blockage of the lumen, the disease is:

• full;
• incomplete, which is also called parietal strangulated hernia;
• open - this variant of the disease is possible only when the appendage of the cecum or Meckel's diverticulum is strangulated.

Depending on the characteristics of development, strangulated hernia is divided into:

• antegrade;
• retrograde;
• false or imaginary;
• sudden.

According to the mechanism of formation, strangulated inguinal hernia in men, women and children, just like any other, exists in 4 types. Thus, we distinguish:

• elastic incarceration - formed against the background of a sudden increase in pressure inside the abdominal cavity, which causes oxygen starvation and death of the tissues of the contents of the sac;
• fecal strangulation of a hernia - occurs in cases of overcrowding of the intestinal loop inside the protrusion with feces. In this case, a disruption of the circulatory process occurs, a disorder of intestinal motor function and the development of adhesions;
• retrograde infringement - occurs when several internal organs are involved in the pathology;
• Richter strangulation of a hernia - in this case, only the edge of one or another internal organ located in the hernial sac is strangulated.

Some patients develop mixed entrapment.

In addition, strangulated hernia occurs:

• primary;
• secondary.

According to the distribution of pathological protrusion, the disease can be:

• external - this includes inguinal, umbilical, femoral and Spigelian hernia;
• internal - this category includes supradiaphragmatic, subphrenic, intraabdominal, epigastric and pelvic hernial sac.

Symptoms

Clinical manifestations will differ slightly depending on which hernia is pinched. However, in all cases, the first and main symptom, against which additional symptoms develop, is pain, which can have varying degrees of intensity.

The following manifestations are typical for strangulated umbilical hernia:

• increase in abdominal size;
• redness and swelling of the skin surrounding the hernial sac;
• increase in local temperature;
• fever;
• nausea and vomiting - vomit may smell like feces;
• violation of the act of defecation;
• lack of gas discharge due to intestinal obstruction;
• the presence of blood impurities in feces;
• weakness of the body;
• tingling in the hernial sac;
• straining of the bulge;
• blood pressure fluctuations.

Signs of a strangulated inguinal hernia include:

• pain shock;
• increased heart rate;
• decreased blood tone;
• retention of stool and gases;
• bloating;
• one-time vomiting;
• pale skin;
• anxiety;
• spread of pain to the epigastric region, groin and thighs;

Symptoms of strangulated hernia of the white line of the abdomen:

• constant nausea with rare vomiting;
• pale skin;
• weakening of the pulse;
• fever;
• state of shock;
• anxiety and restlessness;
• tension and increase in the volume of the bag.

A strangulated diaphragmatic hernia or hiatal hernia may be indicated by:

• frequent belching;
• regular swelling of the anterior abdominal wall;
• shortness of breath and increased heart rate;
• the appearance of a characteristic rumbling sound;
• nausea and vomiting;
• abdominal asymmetry;
• profuse cold sweat;
• increase in temperature indicators;
• swelling and hyperthermia of the skin around the hernia.

Other types of pathology are relatively rare and have similar symptoms.

It is also very important to remember that a strangulated hernia requires first aid, which includes the following manipulations:

• calling an ambulance;
• providing the victim with a horizontal body position;
• ridding a person of tight clothing;
• applying cold compresses to the forehead;
• providing a small amount of liquid;
• ventilation of the room in which the patient is located.

Diagnostics

Due to the presence of a typical clinical picture, any type of strangulated hernia is diagnosed completely without problems. It follows from this that the correct diagnosis can be made already at the stage of the initial examination, which includes:

• study of medical history;
• analysis of life history - this is necessary to find the cause of a strangulated hernia;
• thorough examination and palpation of the pathological protrusion;
• a detailed survey of the patient - to draw up a complete picture of the course of the disease and determine the severity of symptoms.

Additional instrumental examinations may include:

• Ultrasound of the peritoneum;
• radiography with contrast;
• CT and MRI.

A strangulated hernia does not require laboratory tests and differential diagnosis.

Treatment

Regardless of the type of course, location and timing of the entrapment, surgical intervention for hernia excision is indicated. Surgery for strangulated hernia must include:

• release of internal organs that have been infringed;
• resection of the hernial sac followed by drainage and suturing of the wound;
• hernioplasty;
• determining the viability of the components of the pathological protrusion - if necessary, excision of necrotic or atrophied areas is carried out.

Surgery can be performed in several ways:

• in an open way;
• Laparoscopically is currently the most preferred technique.

Possible complications

Ignoring signs of strangulated hernia and untimely treatment of the disease is fraught with the occurrence of:

• dysfunction of the injured organ;
• formation of suppuration;
• death of parts of internal organs located in the hernial sac;

Prevention and prognosis

Preventive measures to prevent strangulation of the hernial sac include:

• timely treatment of hernia of any location;
• preventing an increase in intra-abdominal pressure;
• strengthening the abdominal muscles;
• ensuring that body weight is within normal limits;
• refusal to wear tight belts;
• regular preventive examinations at a medical institution.

A timely operation guarantees a favorable outcome of the disease. Late seeking of qualified help or independent attempts to get rid of the infringement lead to the formation of complications. The mortality rate from this disease is approximately 10%.